Structure, content and data standardization of rehabilitation medical records
10.3969/j.issn.1006-9771.2025.01.002
- VernacularTitle:康复病历的内容结构与数据标准研究
- Author:
Yaru YANG
1
;
Zhuoying QIU
1
;
Di CHEN
2
;
Zhongyan WANG
1
;
Meng ZHANG
2
;
Shiyong WU
3
;
Yaoguang ZHANG
3
;
Xiaoxie LIU
2
;
Yanyan YANG
2
;
Bin ZENG
2
;
Mouwang ZHOU
4
;
Yuxiao XIE
5
;
Guangxu XU
6
;
Jiejiao ZHENG
7
;
Mingsheng ZHANG
8
;
Xiangming YE
9
;
Jian YANG
2
;
Na AN
10
;
Yuanjun DONG
1
;
Xiaojia XIN
1
;
Xiangxia REN
1
;
Ye LIU
2
;
Yifan TIAN
2
Author Information
1. School of Social Development/International Center for Rehabilitation Policy and ICF Research, University of Health and Rehabilitation Sciences, Qingdao, Shandong266113, China
2. WHO-FIC Collaborating Center in China, Beijing100068, China
3. Center for Health Statistics and Information, National Health Commission of the People's Republic of China, Beijing100044, China
4. Department of Rehabilitation, Peking University Third Hospital, Beijing100191, China
5. Department of Rehabilitation Medicine, China-Japan Friendship Hospital, Beijing100029, China
6. The First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu210029, China
7. Huadong Hospital Affiliated to Fudan University, Shanghai200040, China
8. Department of Rehabilitation Medicine, Guangdong Provincial People's Hospital of Southern Medical University (Guangdong Academy of Medical Sciences), Guangzhou, Guangdong510080, China
9. Department of Rehabilitation Medicine, Zhejiang Provincial People's Hospital/People's Hospital of Hangzhou Medical College, Hanghzou, Zhejiang314408, China
10. School of Public Education, University of Health and Rehabilitation Sciences, Qingdao, Shandong266113, China
- Publication Type:Journal Article
- Keywords:
rehabilitation medical records;
medical record data standardization;
International Classification of Diseases;
International Classification of Functioning, Disability and Health;
International Classification of Health Interventions
- From:
Chinese Journal of Rehabilitation Theory and Practice
2025;31(1):21-32
- CountryChina
- Language:Chinese
-
Abstract:
ObjectiveTo elucidate the critical role of rehabilitation medical records (including electronic records) in rehabilitation medicine's clinical practice and management, comprehensively analyzed the structure, core content and data standards of rehabilitation medical records, to develop a standardized medical record data architecture and core dataset suitable for rehabilitation medicine and to explore the application of rehabilitation data in performance evaluation and payment. MethodsBased on the regulatory documents Basic Specifications for Medical Record Writing and Basic Specifications for Electronic Medical Records (Trial) issued by National Health Commission of China, and referencing the World Health Organization (WHO) Family of International Classifications (WHO-FICs) classifications, International Classification of Diseases (ICD-10/ICD-11), International Classification of Functioning, Disability and Health (ICF), and International Classification of Health Interventions (ICHI Beta-3), this study constructed the data architecture, core content and data standards for rehabilitation medical records. Furthermore, it explored the application of rehabilitation record summary sheets (home page) data in rehabilitation medical statistics and payment methods, including Diagnosis-related Groups (DRG), Diagnosis-Intervention Packet (DIP) and Case Mix Index. ResultsThis study proposed a systematic standard framework for rehabilitation medical records, covering key components such as patient demographics, rehabilitation diagnosis, functional assessment, rehabilitation treatment prescriptions, progress evaluations and discharge summaries. The research analyzed the systematic application methods and data standards of ICD-10/ICD-11, ICF and ICHI Beta-3 in the fields of medical record terminology, coding and assessment. Constructing a standardized data structure and data standards for rehabilitation medical records can significantly improve the quality of data reporting based on the medical record summary sheet, thereby enhancing the quality control of rehabilitation services, effectively supporting the optimization of rehabilitation medical insurance payment mechanisms, and contributing to the establishment of rehabilitation medical performance evaluation and payment based on DRG and DIP. ConclusionStructured rehabilitation records and data standardization are crucial tools for quality control in rehabilitation. Systematically applying the three reference classifications of the WHO-FICs, and aligning with national medical record and electronic health record specifications, facilitate the development of a standardized rehabilitation record architecture and core dataset. Standardizing rehabilitation care pathways based on the ICF methodology, and developing ICF- and ICD-11-based rehabilitation assessment tools, auxiliary diagnostic and therapeutic systems, and supporting terminology and coding systems, can effectively enhance the quality of rehabilitation records and enable interoperability and sharing of rehabilitation data with other medical data, ultimately improving the quality and safety of rehabilitation services.
